**2.5. Supplies and vaccines**

Interrupted supply of vaccines has been reported from time to time. Delays in forecasting, procurement, storage, and distribution to the provinces, districts and to the "last mile" (i.e. the hardest to reach segments of the population) have suffered in the past because of unduly tedious procedures [13]. Inadequate maintenance of cold chain is another issue reported in the literature. Power outages are frequent and there is no electricity back up at many places. EPI has state of the art cold chain for vaccine storage and transport; however, its maintenance has been a long-standing issue, particularly in rural remote areas where program monitoring is also weak [26]. Alternative solutions such as solar energy ought to be tried as a backup for power outages.

#### **2.6. Information systems**

Unreliable reporting, poor monitoring and supervision systems, and limited use of local data for decision-making are other impediments in the performance of EPI. Data collection is paper-based at the facility level, and then from district upwards, it becomes electronic. Therefore, establishing its credibility has been a challenge. Moreover, for quite some time, the EPI data was not reflected in the district health information system (DHIS) [27]. Inaccurate immunization records lead to the loss of billions of rupees every year [15]. There is a dearth of health systems research to better understand the dynamics between EPI and the beneficiary population [28].

Demand side issues and community misperceptions are quite high. Ample funds are allocated for social mobilization, yet meager amounts are spent on communication, and to create community awareness of routine immunization [13]. Moreover, a shift of resources from mass media (TV and radio) to community-level, dialogic communication is proposed, given clear evidence that caregivers rely on healthcare providers, family and friends for information about immunization [16]. The demand and supply barriers of EPI have been well summarized

Implementation of the Expanded Program on Immunization (EPI): Understanding the Enablers…

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There are several factors which we can bank upon for improving the EPI immunization program in Pakistan: provincial autonomy as called for in the 18th constitutional amendment, re-enactment of a national ministry of health for coordination, the infrastructure needed for the polio program and the renewed focus of the government and the development partners on routine immunization. No program, however, can improve without looking at it insightfully and searching for the underlying factors that may be the reason for its sub-optimal performance. This monograph has unraveled some important areas that need further exploration. These areas along with key recommendations are summarized here for future research and to broaden the evidence base for the immunization program in Pakistan

**1.** *Financing and resource allocation: The budgetary allocations, spending and reporting has to be made more efficient.* Switching over to a midterm budgetary framework mode could be a good option for EPI. This mode of financing will be performance-based and targetoriented. Funds must be earmarked for the maintenance of cold chain, which is the most vital component of the entire program. Keeping in view the climatic condition of Pakistan, availability of the power source and requirement of the cold chain space according to the target population at each level of hospital i.e. primary, secondary and even at tertiary care facility. Every facility must have an ice lined refrigerator, cold boxes, and vaccines carriers. Funds must be allocated for regular repair and maintenance of the cold chain equipment. Periodic replacement and upgradation of the cold chain equipment is also a requisite that

**2.** *Program governance, management and accountability*: The role of the federal ministry of health and federal EPI cell in the overall coordination of immunization services in the country is pivotal. Forums for 'interprovincial coordination' and 'donor coordination' must be established. Program review meetings held regularly at the federal, provincial, district and health facility levels may help to improve governance of the program. Involving the private sector can also resolve some governance issues. Furthermore, participation of local organizations, community leaders, and volunteers can provide timely feedback to improve

**3.** *Capacity building and human resource*: A fresh review and mapping of the EPI HR and their capacity is required for chalking out a plan for an in-service training. This exercise will bring to light the HR gaps at the federal and provincial EPI cells, and will lead to

(**Table 1**) in an important study undertaken by UNICEF [39].

**3. Discussion and recommendations**

would require appropriate funds allocation.

the immunization services.

and elsewhere.

#### **2.7. Community perceptions and behaviors**

Low community awareness and misbeliefs that vaccines cause disease, and the doubts about vaccine safety and effectiveness have been reported as important factors, impeding the uptake of immunization, especially in case of polio [29]. Therefore, educating the masses and population segments with low literacy levels, especially the women, is a must for improving the utilization of immunization services [30]. Gender differential in immunization coverage needs innovative gender mainstreaming strategies at the community level such as employing more female vaccinators and community volunteers for outreach to women [31]. Community activists can also encourage people to seek immunization services, and can increase demand through educating various community segments [32]. Communication between immunization workers and the parents of children has been flawed, and a positive engagement has helped with overcoming the resistance to vaccinations [33]. On the other hand, service providers in clinics do not emphasize the importance of immunization [34]. Religious beliefs and lack of knowledge about the benefits of the vaccines still dictate many pockets of this highly diverse and populated country [35]. Targeted community awareness programs, a robust surveillance network, and engagement with the dominant religious entities can help to root out the issue [36, 37]. Better understanding of the religion and soliciting local support for vaccination campaigns may assist in negotiating access in the areas where refusal is an issue [38].


**Table 1.** Demand and supply side barriers in effective implementation of EPI.

Demand side issues and community misperceptions are quite high. Ample funds are allocated for social mobilization, yet meager amounts are spent on communication, and to create community awareness of routine immunization [13]. Moreover, a shift of resources from mass media (TV and radio) to community-level, dialogic communication is proposed, given clear evidence that caregivers rely on healthcare providers, family and friends for information about immunization [16]. The demand and supply barriers of EPI have been well summarized (**Table 1**) in an important study undertaken by UNICEF [39].
